A psychiatric evaluation without medication management is a comprehensive, diagnostic assessment conducted by a licensed clinical professional—such as a psychiatrist, psychiatric nurse practitioner, psychologist or Licensed Clinical Social Worker—focused on evaluating an individual's mental health status, diagnostic formulation, and treatment needs without the initiation or ongoing management of psychotropic medications.

The purpose of the evaluation is to:

• Gather detailed clinical history, including psychiatric, medical, developmental, and psychosocial factors

• Assess current symptoms and patterns of emotional, behavioral, and cognitive functioning

• Determine the presence of mental health disorders using DSM-5 criteria

• Evaluate risk factors (e.g., suicidality, self-harm, substance use, aggression)

• Conduct a mental status examination (MSE)

• Identify contributing factors such as trauma, stressors, or environmental influences

• Make recommendations for appropriate levels of care and treatment modalities (e.g., psychotherapy, behavioral interventions, community support)

While this evaluation may consider the potential role of medication in the client’s overall treatment plan, no prescriptions or pharmacologic interventions are provided or managed as part of this service. Instead, the clinician may refer the client to a prescriber if medication is indicated, or coordinate with other providers as part of a multidisciplinary care approach.

This type of evaluation is often used to support:

• Diagnostic clarification

• Therapy planning or referrals

• Legal, occupational, or educational assessments

• Court-mandated mental health evaluations

• Treatment team collaboration